Hi All,I work in a very fast paced acute care setting. I take care of the inpatient cardiovascular section.I see CABGs and Thoractomies as early as day one.My question is regarding the CABG PT intervention..an important part of my intervention is educating the pts for the sternotomy precautions-eg not lifing wt over 10 lbs with UEs, not to push and pull with UE, how get out from the bed with max use of legs and min use of arm..these are a few of the precautions.I am thinking of giving an inservice (and may b give a handout to pts with sternotomy precaution instrcution)about the precautions.

Can anybody throw some light on the above topic ? Is there anyone who practices in the same kind of setting ?

I know the acute care section of APTA had an article about the sternotomy precautions.

My father recently had open heart surgery, and when I questioned his surgeon about these types of precautions, he was very vague and didn't seem to think they were very important, other than a general "take it easy" kind of approach. (That is when His Highness the Cardiac Surgeon deigned to speak to a serf such as I).He said something about the sternal repair being much stronger in recent years, and that the precautions weren't necessary.He did fine, he even used his UEs for transfers and most ADLs with no limits. I mean, he wasn't bench pressing or anything. :) It seems perhaps the sternotomy precautions are no different than the activity limitations imposed by the cardiac surgery itself?Food for thought...J

The important aspect in the early phase post-surgery is to make sure all movements are bilateral - using a Jacob's ladder to pull on when sitting up from lying down etc. Sternal separation is not the problem it used to be; but some people wil still experience ongoing sternal/chest pain if they do too much unilateral UE work.

Unfortunately, cardiac precautions in my experience are dictated by physician preference. I work in acute at a large University and our CT faculty do not really care about the precautions as Jason indicated. In 8 years, I have never seen a problem. On the other hand, at another for-profit hospital that I work at, the CT surgeon is adamant regarding sternal precautions and does not allow patients to use a walker. He would rather them be assisted by hand held. Two extremes.

The same goes for mobilizing patients with acute DVT, high INR (>4), and low Hgb (<8). It varies from one physician to another and there are no definitive answers in the literature.

By the way, something that I did not see in your post is the use of a pillow to hug for rolling, coughing, etc. I have found these to be really helpful for patients. We give each CT patient a small pillow to hug for an external counterpressure on the sternum. Patients love 'em and typically walk the hallways hugging the heart-shaped pillow which all of us sign upon discharge.

Tucker, unless you plan on dropping the patient, why would you worry about walking a patient with an INR of 4? Lots of patients are walking around the mall with an INR of 4.Just curious to hear your line of thought.Thanks

We have a few MDs (over 65 years of age) who will hold PT mobilization if INR is over the therapeutic range of 2-3 after acute DVT. There is nothing that we can do to convince them it is safe. Our trauma faculty told me he is fine with mobilization up until INR of 5 due to risk of spontaneous bleeding. Then a plastics faculty told me no problem even at a 6, as long as they don't fall.

With regards to low Hgb, there was an article in an acute PT journal from the 80s that said NO EXERCISE IF HGB IS BELOW 8. Many PTs still go by this rule unfortunately. Sure if the patient is waiting on a transfusion or is symptomatic, by all means we should hold...but there are times that it is fine...such as patients that refuse a transfusion due to religious beliefs or if they are asymptomatic. We've successfully mobilized several ICU patients with Hgb below 7, heck even at a 4. Our trauma faculty does not transfuse healthy patients until Hgb is at a 6 so we would be holding therapy for many patients if we went by that recommendation.

Yeah...that is all nonsense, I agree with your plastics and trauma faculty. I see people ALL THE TIME with incidental INR's of >4, they come in with unrelated complaints. The only way they will spontaneously bleed is if they 1. pick their nose 2. you drop them or push them down 3. you cut them 4. the valsalva and create a small hematoma.

There is GREATER risk of spontaneous bleeds with Plavix.

As for low hemoglobin...women menstrate to a level of 10 often. Their concerns are overblown it is the cause of the anemia that is more concerning NOT the number. You as a therapist are going to do NOTHING to worsen their anemia.

This was a very interesting discussion. I am late - a newbie to the RehabEdge forum - so please excuse the late thoughts. I think many of the topics being discussed here regarding sternal precautions, INR's, HgB's, highlight an important aspect of clinical practice. It is extremely difficult to apply a measure of one aspect of a system to make a decision about system level response. I think the inherent complexity in such areas is where research becomes limited by sample size and a lack of full variation in all possible strata; and where clinical decision making has to fill in the gaps with solid reasoning - as you all have demonstrated in the above discussion.Best - Sean